Everyday healthcare professionals have to deal with agitated, aggressive, and potentially violent patients in their workplace, most commonly in the emergency department of the hospital. There can be a multitude of factors which can cause patients to disturb others around them with their aggressive behaviours, but guidelines must be set in place to restrain potentially violent and abusive patients, and if necessary, to sedate them also.

When should emergency physical restraint be used?

One of the key principles of medical ethics is that a patient’s independence and body should be respected; therefore physical restraint should only be used when absolutely necessary for the safety of the patient themselves and others around them. Physical restraint should be considered as a last resort. If, however, the patient is being aggressive and does not require immediate medical or psychiatric care, then they should be freely discharged to another safe environment, such as their home or over to the police if necessary (1).

If the patient requires urgent medical or psychiatric treatment, and has not responded well to other methods of behaviour control techniques to calm them down, then physical restraint and/or sedation is typically recommended as the next course of action. Other indications for restraint include when the patient is becoming increasingly aggressive, especially towards others around them, as well as destructive behaviour towards hospital property, due to their medical or psychiatric condition, or even due to intoxication.

Alternative methods to calm a patient

If a patient history indicates that the patient may be prone to irritable behaviour and becoming hostile, then for the safety and comfort of everyone involved, it is best to call on a mental health expert beforehand, such as an on-call psychiatry registrar or an intake worker.

The healthcare professional who is taking care of the patient should be able to carry out their assessment and medical treatment in a confident supportive manner in a safe environment. This means there should be minimal interruptive stimuli available to the patient, and that the healthcare provider should listen and talk to the patient’s concerns with a calm demeanour. If the patient is showing signs of cooperation, then it is advisable to offer a planned oral sedation so that they may reclaim control of their thoughts and actions.

Carrying out emergency restraint and sedation

An essential aspect to consider when about to physically restrain a patient is that a co-ordinated team response should be carried out; meaning each member of the team is aware of their particular role to play so that instant and immediate action is taken. The Code Grey procedure should be followed for the safety of the whole medical staff and the patient at hand, and unless otherwise indicated, sedation of the patient should also follow.

Medical staff should be aware of the patient’s previous medical history, medications, and substance use (if any) before any emergency sedation is administered. Staff should also be aware and cautious if there are not enough trained personnel available to carry out the physical restraint, as well as if required equipment is inadequate or the environment is deemed unsafe. If the patient presents with a weapon and the situation is escalating dangerously then security and police should be alerted (1).

All patients should be given the option to take medication orally whenever possible. When a patient is confirmed to be intoxicated then benzodiazepines are the preferred medication. If the patient history shows that the patient suffers from a psychiatric disorder, then the first choice would be to increase dosage of their usual medication. More drug specific information is available; it is advised that if a drug from one group has a non-satisfactory therapeutic response after two doses, then a different drug from another group should be considered (2).

The Code Grey Procedure

The Code Grey procedure can be broken down into the following steps (2);

1. A team with pre-designated roles should perform the emergency restraint and sedation on any patient deemed potentially violent and aggressive.
2. Team members should ensure their own safety, with gloves and goggles when appropriate and medication ready at hand.
3. With the least amount of force possible, the patient should be secured face upwards lying down on the floor. If the patient is thought to be highly irritable, then the face down position may be used to secure them, however the team must be cautious to avoid asphyxia.
4. Quickly yet carefully administer the sedative drug, either by oral administration when the patient shows signs of co-operation or by intramuscular injection.
5. Offer post-sedative care.
6. If the patient is still showing signs of aggressiveness and potential violence, then specially trained personnel may mechanically restrain the patient also.

Post sedative patient care

The patient should be monitored carefully after physical restraint and sedation, especially for any symptoms of respiratory depression, obstruction to their airway, or hypotension. This monitoring is to be done within the clinical setting and can be done flexibly to avoid needlessly irritating the patient further.

Patients should be treated according to their level of consciousness and agitation. If the patient has a decreased level of consciousness then vital signs should be regularly monitored until stability is regained. If the patient appears to be alert but in a calmer state of mind then half-hourly monitoring is acceptable, whereas a patient who is still disturbed should be continuously observed (1).

All medications and the reason behind the patient restraint should be documented in the patient’s medical record. This should be a detailed documentation including the times, and a Code Grey reporting form should be filled out. It is useful to add in the patient’s physiological response to the sedation administered, any complications that were faced and also the results of the on-going monitoring for the post-sedative patient care (1).



Source:

The Royal Childern's Hospital Melbourne